2.3. Community health insurance
schemes in Rwanda
Community health in Rwanda embraces the concept of primary
healthcare which is defined as an essential healthcare based on practical,
scientifically sound and socially acceptable methods and technology made
universally accessible to individuals and families in the community through
their participation and at a cost that the community and country can afford to
maintain at every stage of their development in the spirit of self-reliance and
self-determination. (WHO, Alma-Ata Declaration, 1978)
It forms an integral part both of the country's health system,
of which it is the central function and main focus, and of the overall social
and economic development of the community. It is the first level of contact for
individuals, family members and the community with the national health system,
bringing healthcare as close as possible to where beneficiaries live and work,
and constitutes the first element of a continuing healthcare process (WHO,
Alma-Ata Declaration, 1978). Rwanda has lived one of the most tragic
moments of its history with the genocide of 1994, which resulted in nearly one
million deaths and the destruction of the social fabric of the country.
Her recent history has been proved as one of tragedy and
despair. The country has faced immense development challenges after the
genocide of 1994. These include the challenges of providing adequate social
services such as health services to the population given the prevailing
circumstances. In this respect, the government of Rwanda introduced the
community based insurance schemes to ease access to healthcare services
especially for the rural poor. (WHO, Alma-Ata
Declaration, 1978)
2.4. Current problems of mutual
health insurance schemes in Rwanda
According to the Ministry of health (ROR2004:4), mutual health
initiatives or schemes like any other forms of organizations are not immune to
various hardships problems as mentioned below. First, mutual health insurance
schemes are insufficiently designed and this often results in a difficult start
of the health insurance scheme. In many cases, there is no in-depth
consideration (e.g. through a feasibility study) of the interest which the
target population has in the exogenous insurance concept, what it is willing or
able to pay for the scheme and what services it expects. It is equally
important to identify the specific disease burden of the target group. (WHO,
Alma-Ata Declaration, 1978)
When the level of insurance premiums, co-payment and benefit
package are defined, attention is not always paid to the financial
sustainability of the health insurance scheme. A high level of claims for
services (moral hazard), adverse selection of members and the problem of free
riders have to be avoided. The second problem concerns insufficiency of
information and participation of the target group as potential members lack a
significant say in the shaping of the scheme, and they also lack sufficient
information at then disposal on the functional principles of their health
schemes. (WHO, Alma-Ata Declaration, 1978)
Thirdly, mutual health insurance schemes lack management. Many
local health insurance schemes are run by a voluntary management team in order
not to impose too high a financial burden on these relatively small initiatives
through high administrative costs. This leads to the situation where those
responsible have hardly any insurance expertise and at the same time pursue
their own individual activities to earn a living. Many health insurance schemes
thus lack any rigorous mechanisms of cost control and claims examination, or
regular information services and marketing for member recruitment. (Schneider
et al. 2004:24).
Another problem is low membership. Many health insurance
initiatives suffer from very low membership numbers, which results amongst
other things from the problems discussed above. As soon as disease cases with
very high costs occur, this can mean the end of the health insurance scheme due
to insufficiency of pooled resources. Starting in 2001, an adaptation phase
drawing on lessons learned and recommendations from the pilot phase extended
the number of CBHI schemes and increased enrolment rates in individual schemes.
(Schneider et al. 2004:24).
Consequently, on July 2003, ninety-seven CBHI schemes,
covering half a million Rwandans, where functional in the country and some
scholars have regarded them as viable tools for sound financial investment to
both an individual and to the society as a whole. The development of mutual
health insurance schemes is currently in an extension phase: in 2004, two
hundred and fourteen (214) CBHI schemes have been established around the
country as result of the combined efforts of promotional activities of central
authorities (Ministry of health an Ministry of local Affairs), provinces,
districts, local health personnel, local opinion leader and non-government
organizations. In mid-2004, national coverage of CBHI schemes was estimated at
1.7 million which is about 21% of the Rwandan population (Schneider et al.
2004:24).
According to the Ministry of health (ROR 2004:4), the
establishment of mutual health insurance has been on the rise considering the
first five years. In fact, the number of mutual health insurance schemes rose
from six in 1998 to 76 in 2001 and 226 in November 2004. The geographical
coverage of the mutual health insurance was also extended: whereby in 1999,
these mutual health insurance schemes were mainly functional in the four former
provinces of the country which are Butare, Byumba, Gitarama and Kibungo, they
have since September 2004, been established in virtually all the former eleven
provinces of the country, as well as in Kigali city and they covered 2,101,034,
beneficiaries representing 27% of the population in Rwanda. (ROR 2004:4)
External assistance for healthcare continues to be significant
revenue source in low-income countries such as Rwanda, where it financed about
27 percent of total healthcare, leaving an estimated 9 percent to the Rwandan
government. Healthcare in Rwanda is relatively expensive compared to other
goods. In 1997, the medical consumer price index (CPI) scored 30 percent above
the general CPI in Rwanda. From 1997 to 1998, the general CPI increased by 37
percent and the medical component, already high, increased by 5 percent (Kalk
et al. 2009).
Schneider et al. (2008:15), confirms that contributions to the
CBHI scheme funds in Rwanda are on yearly basis. Members have the option to
sign up as a family with up to seven members, which costs us $ 7.6 per family
per year, payment of the yearly premium entitles covered family members to a
benefit package which includes all preventive, curative, services, prenatal
care, delivery care, laboratory exams, drugs on the MOH essential drug list,
and ambulance transport the district hospital provided by the partner health
centers. (ROR 2004:4)
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